Insulin-Dependent Diabetes Mellitus (IDDM): Anesthetic Implications and Perioperative - PowerPoint Presentation

Slide1

Insulin-Dependent Diabetes Mellitus (IDDM): Anesthetic Implications and Perioperative Management

Odinakachukwu Ehie, MDClinical Assistant ProfessorUCSF Benioff Children’s Hospital

Slide2

Disclosures

No relevant financial relationships

Slide3

Learning Objectives:

Discuss diabetes mellitus and the importance for anesthesia providers to know about itReview symptoms and diagnostic criteria for insulin-dependent diabetes

Provide guidelines in the management of insulin-dependent diabetes mellitus as well as fasting recommendations prior to surgery

Discuss the importance of a multidisciplinary approach for perioperative management

Discuss diabetic ketoacidosis and management

Slide4

Overview

Diabetes mellitus

Most common metabolic disorder in pediatric patients

Increasing global incidence

Diabetes mellitus is characterized by high blood glucose levels from defects in

insultin

secretion and/or action

Perioperative blood glucose control can be challenging

:

Physiological and metabolic stress as well as disruptions in routine

Maintain electrolyte balance and optimal hydration

Communicate with surgeons, pediatric diabetes team, and ward staff to facilitate optimal care

Slide5

Classification of Diabetes Mellitus

Type 1 or insulin-dependent diabetes mellitus (IDDM)

Serious chronic disease seen mostly in children or adolescents

Most prevalent form of childhood diabetes

Associated

with other autoimmune diseases, including hypothyroidism and celiac

disease

Type 2 diabetes mellitus: more common in obese or older patients

Slide6

Classification

Type

1

Type 2

Absolute

deficiency of insulin secretion

Resistance to

insulin action

Diagnosis via blood tests for genetic

markers

Diagnosis via measuring blood glucose levels

after fasting or oral glucose challenge

Insulin

required for survival

Insulin required

for control

Slide7

Pathophysiology of IDDM

Slide8

Criteria for Diagnosis

1) Fasting plasma glucose > or = 7.0 mmol/l (126 mg/dl)

(no caloric intake for at least 8

hrs

)

2) 2-hr plasma glucose > or = 11.1mmol/l

(200mg/dl) during an oral glucose test trial (75 g anhydrous glucose in water)

3) Hb A1C > or = 6.5%

(False reading in patients with anemia and hemoglobinopathies)

4) Plasma glucose > or = 11.1

mmol/l (200mg/dl) in a patient with classic symptoms of hyperglycemia

*Only

one required for diagnosis of diabetes

Slide9

Symptoms

Classic symptoms of significant hyperglycemiaPolyuriaPolydipsia

Weight Loss

Polyphagia

Blurred Vision

Growth impairment

Susceptibility to infections from chronic hyperglycemia

Diabetic ketoacidosis

 life-threatening

Slide10

Type 1 diabetes (IDDM)

Autoimmune diseaseIDDM must be considered in any pediatric patient who continues to urinate regularly despite clinical dehydrationPatients require insulin for normal growth and development in puberty

Normal goal of fasting blood glucose: 4-6 mmol/L (70-110 mg/dL)

Types of insulin:

Prandial insulin



given around meals

Basal insulin

 once or twice daily

Premixed insulin  biphasic insulin that includes prandial and basal

Slide11

Insulin Management -Prandial

Prandial Insulin

Onset

Peak (

hr

)

Duration (

hr

)

Timing of Insulin

Rapid-acting

insulin:

-Humalog (Lispro)

-

Novorapid

(

Aspart

)

-

Apidra

(

Glulisine

)

0-15 min

10-20

min

5-15 min

1

1-3

1-2

3.5 - 4.5

3-5

3-5

5-15 mins before

or immediately after eating

Short-acting

insulin:

-

HumulinR

-

Actrapid

30 min

30 min

2-4

1-3

6-8

8

30

mins before eating

Slide12

Insulin Management -Basal

Basal Insulin

Onset

Peak (

hr

)

Duration (

hr

)

Timing of Insulin

Intermediate-acting,

NPH

- Humulin N

-

Insulatard

1

hr

1.5

hr

4 – 10

4 - 12

16 – 18

18 - 23

Before

breakfast /before bed

Long-acting insulin

- Detemir

Glargine

1

hr

2 - 4

hr

no peak

no peak

17 – 23

20 – 24

Same

time everyday

Slide13

Insulin Management -Premixed

Premixed Insulin

Onset

Peak (

hr

)

Duration (

hr

)

Timing of Insulin

Premixed human (30%

regular + 70% NPH)

- Humulin 30/70

-

Mixtard

30

30 min

30 min

Biphasic

Biphasic

16 - 18

18 - 23

30

-60 mins before eating

Premixed analogue:

- Humalog

Mix 25

(25% lispro + 75% lispro protamine)

-

Novomix

30

(30%

aspart

+70%

aspart

protamine)

0-15

min

10-20 min

Biphasic

Biphasic

16-18

18-23

5-15 mins

before eating

Slide14

Less Common Causes of Diabetes in Children

Slide15

Perioperative Metabolic Burden

Hypoglycemic episodes can occur from:Perioperative fasting

Overuse of insulin infusions

Children have lower glycogen reserves

 greater incidence of hypoglycemic episodes  adverse effects on developing brain

Hyper

glycemic episodes can occur from:

Critical illness

Neuroendocrine stress response to surgery

Slide16

Guidelines for Perioperative Management

Optimized analgesia can reduce stress-induced hyperglycemia Regional blockadeOpioids

Adjuvant analgesics

Perioperative target for blood glucose:

5

–

10

mmol

/l

(90

–

180 mg/dl)

Active treatment is recommended when the blood glucose:

< 5

(90 mg/dl) or

> 14 mmol/l

(250 mg/dl)

Consider monitoring blood glucose at least once every hour in children < 3

yr

and in patients undergoing major surgeries

Consider more frequent monitoring if the blood glucose is <

5 mmol/l

(90 mg/dl)

Slide17

Preoperative Assessment

Obtain following labsSerum electrolytesHbA1c

Current blood glucose

Blood/urinary ketones

Postpone elective surgery if glucose is poorly controlled

Schedule diabetic children to be first case of the day when possible

Fasting guidelines

Clear fluids up to 2

hrs

prior to surgery

Breast milk up to 4

hrs

prior to surgery

Formula or solid food up to 6

hrs

prior to surgery

Slide18

Insulin Management in Minor Elective Surgeries for IDDM

Slide19

Insulin Management in Major Elective Surgeries for IDDM

Slide20

Insulin Sliding Scale

Dilute 50 units of soluble insulin in 50 ml 0.9% NS (1 U/ml)Monitor blood glucose every 30 - 60 minutes peri-operatively until patient resumes PO intake

Stop IV insulin sliding scale if blood glucose is < 4mmol/l, and give 2 ml/kg IV 10% dextrose

Restart the IV insulin sliding scale when blood glucose is > 4 mmol/l

Slide21

Insulin Sliding Scale

Blood Glucose

Sliding Scale Rate

< 4 mmol/l

0.01 U/kg/

hr

and 2ml/kg 10% dextrose

4

–

6.9

mmol

/l

0.02 U/kg/

hr

7

–

9.9

mmol

/l

0.03 U/kg/

hr

10

–

12.9

mmol

/l

0.04 U/kg/

hr

> 13 mmol/l

0.05 U/kg/

hr

Slide22

Insulin Management in Elective Surgeries for Type 2 Diabetes

Slide23

Emergency Surgery

Multi-disciplinary team approachPreoperative evaluation:Weight

Hydration status

Blood glucose

Serum electrolytes

Blood or urinary ketones

Diabetic Ketoacidosis (DKA) can occur from acute illness

Correct circulatory and metabolic status before surgery if time permits

For non-keto-acidotic patients, start IV fluids and sliding scale insulin

Slide24

Diabetic Ketoacidosis (DKA)

Slide25

Diagnosis of DKA

Common and potentially life-threatening acute complication of IDDMAnion gap metabolic acidosisCan occur with stress inducing illness in setting of insulin deficiency

Diagnostic criteria

Blood glucose > 14mmol/l (250mg/dl)

pH less than 7.2 or 7.3

Low bicarbonate level

Urine ketones

Slide26

Management of DKA

Administer IV fluids

–

do

NOT

rely on urine output as sign of good hydration

Rapid fluid administration

 cerebral edema

Delay in starting insulin can be detrimental

Add glucose to IV fluids to prevent hypoglycemia

Continue insulin infusion until patient’s acidosis resolves

Stop IV insulin before starting subcutaneous insulin

Give subcutaneous insulin before meal

Slide27

Conclusions:

DM is the most prevalent metabolic disorder in pediatric patientsInsulin-dependent diabetes mellitus requires close perioperative blood glucose monitoringMultidisciplinary team approach is optimal

Resume normal oral intake and diabetes management as soon as possible postoperatively

DKA treatment involves insulin, IV fluid and electrolyte replacement (carefully monitor potassium)

Challenges in LMICs include adequate refrigeration for insulin and availability of

glucose monitors

Slide28

References:

Tjen, C., Wilkinson, K. Perioperative care of children and young people with diabetes. British Journal of Anaesthesia. 2016;16(4):124-129.

Lewis, H. Perioperative management of infants and children with diabetes.

WFSA

Anaesthesia

Tutorial of the Week

. (Tutorial 402). 16 April 2019.

American Diabetes Association. Diagnosis and classification of diabetes mellitus. Diabetic Care. 2010;33:S62-S69.

Plotnick

, L. Insulin-dependent Diabetes Mellitus. Pediatrics in Review. 1994;15:137-148.

Fasting recommendations for patients with insulin-dependent diabetes. Medscape. Feb 15, 2017

Suzuki, et al. Glycemic control indicator levels at diagnosis of neonatal diabetes mellitus: Comparison with other types of insulin-dependent diabetes mellitus. Pediatric Diabetes. 2017;18:767-771.

Zanaria,H

., et al. Practical guide to insulin therapy in type 2 diabetes. Guidebook from Malaysian Ministry of Health. 2011.

Lanzinger

, S., et al. Comparing clinical characteristics of pediatric patients with pancreatic diabetes to patients with type 1 diabetes: A matched case-control study. Pediatric Diabetes. 2019;20:955-963.